North Central State College
Financial Aid Office
2014/2015
Student Name (print) _____________________________________ NCSC I.D. __________________
he FAFSA (Federal financial aid application) is designed to determine a family’s ability to pay for
college at a particular point in time. Recognizing that family financial situations can change, colleges
have the authority to consider some changes which are beyond the family’s control when financial aid
eligibility determinations are made.
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These changes, or special circumstances, could include, but are not limited to, involuntary loss of employment
or untaxed benefits, or having to pay for unusually high medical expenses. Discretionary changes such as
voluntary termination of employment or expenses such as paying for normal living costs are not
considered to be special circumstances. In evaluating current year changes, the family’s entire financial
situation is reviewed, and only when a significant reduction in the family’s ability to pay for college is
established, can special circumstance adjustments be made.
The Financial Aid Office has exclusive authority regarding all policies and procedures relating to special
circumstances. Submitting a petition does not guarantee an increase in financial aid eligibility and does not
obligate the Financial Aid Office in any way. Processing a petition may take several weeks or longer to complete.
The process
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The FAFSA is completed using the financial information specified in the FAFSA instructions.
A family affected by financial changes completes this special circumstance petition and submits it along
with all required documentation to the NC State Financial Aid Office (FAO).
The FAO determines, as precisely as possible, the dollar amount of the change.
If the amount of the change is not significant, no adjustment is made.
The dollar amount of changes significantly affecting a family’s ability to pay for college is sent to the
FAFSA processor.
The FAFSA processor recalculates eligibility and reports new information to the College and student.
The FAO makes a new financial aid award based on the FAFSA processor’s revised calculation.
The petition form
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Complete all five parts of this form.
Be as complete and precise as possible.
Provide thorough documentation including copies of 2013 federal tax returns and W-2 forms.
1. Indicate with an “X” your special circumstance or the reason for your loss of income.
Family changes
   Disability--Provide a letter from a doctor describing the disability and giving a prognosis for returning
to work. Include a letter verifying monthly disability benefits from Social Security, Workers’
Compensation, employer, or other agency.
   Separation or divorce after the FAFSA has been filed--Provide a copy of the divorce decree or
separation agreement.
  Death of a parent or spouse after the FAFSA has been filed--Provide a copy of the death certificate.
143 Kee Hall
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2441 Kenwood Cr. • Mansfield, Ohio 44906
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419-755-4899
Unusual expenses
 Medical and Dental Expenses—Your family pays medical or dental expenses that are not covered by
insurance and these expenses exceed 10 percent of total family income. Provide a copy of Schedule A
of the previous year’s federal tax return, copies of canceled checks, or other documentation of medical
and dental expenses that were actually paid and when they were paid.
 Elementary and Secondary Education Paid--You have paid for elementary, junior high, or high
school tuition in the previous calendar year for dependents in your family (not to exceed $4,000 per
child). Provide a letter from the school stating the amount you have paid for tuition in the previous
calendar year.
Loss of income from work. The action resulting in the loss of income must have occurred at least ten weeks
prior to this request for special circumstance consideration.
 Layoff--Provide a letter from the employer stating the effective date and anticipated date of return.
 Involuntary hour or wage reduction--Provide a letter of explanation from the employer.
 Involuntary termination--Provide a letter from the employer stating the effective date. If this is not
available, provide documentation from the local unemployment office.
Loss of other taxable income
 Alimony--Provide a letter of explanation from a court official which includes the effective date/s.
 Unemployment compensation--Provide documentation from the unemployment office stating the
termination date of benefits.
 Other--Explain and provide appropriate documentation.
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Loss of untaxed income
 Child support--Provide a letter or court document stating the termination date of benefits.
 Workers’ Compensation--Provide documentation from the Bureau of Workers’ Compensation stating the
termination date of benefits.
 Other--Explain and provide appropriate documentation.
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2. Current Calendar Year Estimated Income
Enter the total income that you, your spouse, and (if you are dependent on the FAFSA) your parent(s)
expect to receive from January 2014 thru December 2014. If an income source does not apply to you,
enter $0 in the response space. Thoroughly explain in Part 4 of this form how you determined your
expected income.
Estimated Taxable Income for Calendar Year 2014
Student & Spouse
Wages, salaries, tips
Parents
Student $_____________
Father $_____________
Spouse $_____________
Mother $_____________
Pensions and annuities
$____________________
$____________________
Interest and dividends
$____________________
$____________________
Business and farm income
$____________________
$____________________
Alimony
$____________________
$____________________
Unemployment compensation
$____________________
$____________________
Other____________________
$____________________
$____________________
________________________
$____________________
$____________________
Estimated Untaxed Income for Calendar Year 2014
Child Support received
$____________________
$____________________
Workers Compensation
$____________________
$____________________
Retirement or Disability income
$____________________
$____________________
Housing benefits
$____________________
$____________________
Cash paid on your behalf
$____________________
$____________________
Other____________________
$____________________
$____________________
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$____________________
$____________________
3. Family Members
Identify all persons in your family. Also identify the college at which any family member will be
enrolled in a degree program at least half-time beginning July 1, 2014.
Full Name
Age
Relationship to You
College Attending, if Any
Self
North Central State College
4. Narrative Explanation of Special Condition
Why are you asking that your financial aid eligibility reviewed? Explain fully the change(s) which have
affected your family’s financial situation in 2014. Also, explain how you determined your income as
stated in Part 2 of this form. Use an additional sheet if necessary.
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5. Certification
Each person making this certification agrees to the following:
All of the information on this form and on supporting documentation is true and complete to the
best of my knowledge. If asked, I agree to provide additional verification documentation. I
understand that if I purposely give false or misleading information, I am violating Federal law and
I may be subject to a fine, imprisonment, or both.
Student signature _____________________________________________ Date_________________
Spouse signature _____________________________________________ Date__________________
Mother’s signature ____________________________________________ Date__________________
Father’s signature_____________________________________________ Date__________________